EUROHEALTHNET’s RESPONSE TO PUBLIC CONSULTATION ON THE EUROPE 2020 STRATEGY

A) Background for the public consultation:

The Europe 2020 strategy was launched in March 2010 as the EU's strategy for promoting smart, sustainable and inclusive growth. It aims to achieve a knowledge-based, competitive European economy while preserving the EU's social market economy model and improving resource efficiency. It was thus conceived as a partnership between the EU and its Member States driven by the promotion of growth and jobs.

The Europe 2020 strategy is built around five headline targets in the areas of employment, research and development, climate and energy1, education and the fight against poverty and social exclusion. The strategy also set out a series of action programmes, called "flagship initiatives", in seven fields considered to be key drivers for growth, namely innovation, the digital economy, employment and youth, industrial policy, poverty and resource efficiency. The objectives of the strategy are also supported by action at EU level in areas such as the single market, the EU budget and the EU external agenda.

The Europe 2020 strategy is implemented and monitored in the context of the European Semester, the yearly cycle of coordination of economic and budgetary policies at EU level. The European Semester involves discussion among EU institutions on broad priorities, annual commitments by the Member States and country-specific recommendations prepared by the Commission and endorsed at the highest level by leaders in the European Council. These recommendations should then be taken on board in the Member States' policies and budgets. As such, together with the EU budget, the country-specific recommendations are key instruments for the implementation of the Europe 2020 strategy.

After four years, the Commission has proposed, and the European Council of 20-21 March 2014 has agreed, to initiate a review of the Europe 2020 strategy. On 5 March 2014, the Commission adopted a Communication "Taking stock of the Europe 2020 strategy for smart, sustainable and inclusive growth" (Communication and Annexes ). drawing preliminary lessons on the first years of implementation of the strategy. Building on these first outcomes and in a context of a gradual recovery of the European economies, it is time to reflect on the design of the strategy for the coming years.

1 In January 2014 the Commission launched a framework for energy and climate policies up to 2030. A reduction in greenhouse gas emissions by 40% below the 1990 level, an EU-wide binding target for renewable energy of at least 27% and renewed ambitions for energy efficiency policies are among the main objectives of the new framework.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 Through these questions, we are seeking your views on the lessons learned from the early years of the Europe 2020 strategy and on the elements to be taken into account in its further development, in order to build the post-crisis growth strategy of the EU.

B) Questions:

1) Taking stock: the Europe 2020 strategy over 2010-2014

Content and implementation

 For you, what does the Europe 2020 strategy mean? What are the main elements that you associate with the strategy?

EuroHealthNet has consulted its members and partners as the responsible and accountable bodies in Europe for health promotion and tackling health inequalities, working at European Union levels since the first competence in public health was implemented following the provisions of the ‘’Maastricht Treaty’’. We therefore judge this strategy against the two most crucial aspects of the revised TEU from this perspective:

(a) THE OBJECTIVES OF THE UNION

Article I-3 of the Constitutional Treaty, which covers the internal and external objectives of the Union, merges the provisions of the EU Treaty and those of the EC Treaty. These objectives must guide the Union in the defining and implementation of all its policies.

The main objectives of the Union are now to promote peace, the Union's values and the well-being of its peoples.

These general objectives are supplemented by a list of more detailed objectives:

(a) an area of freedom, security and justice without internal frontiers ; (b) an internal market where competition is free and undistorted; (c) sustainable development, based on balanced economic growth and price stability, a highly competitive social market economy, aiming at full employment and social progress, and a high level of protection and improvement of the quality of the environment; (d) the promotion of scientific and technological advance; (e) the combating of social exclusion and discrimination, and the promotion of social justice and protection, equality between women and men, solidarity between generations and protection of the rights of the child; (f) the promotion of economic, social and territorial cohesion, and solidarity among Member States

(b) Article 168

1. A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities.

EuroHealthNet recognises the analysis contained within COM (2014) 130 concerning steps taken since the initiation of the 2020 strategy in 2010, and place on record our appreciation of the efforts of numerous officials and stakeholders in the EU institutions and in Member States to

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 meet needs within the realities of EU governance. However we regrettably consider that, while the aims of EU 2020 can contribute to achieving most of the above Treaty objectives, in reality the practice and implementation amounts to crisis management rather than sustainable development.

That means that the situation and prospects for equitable wellbeing development in the EU have not improved during this period and significant change is needed in the period 2015 – 2020 and beyond.

For evidence – and potential solutions based on that evidence - we refer in particular to extracts from the relevant contents of the WHO Europe 2014 publication ‘’Economic crisis, health systems and health in Europe: impact and implications for policy’’ - ISSN 2077-1584, WHO Observatory Policy Summary 12.

‘’ Public spending on health fell or slowed in many countries between 2007 and 2012, both in absolute terms and as a share of government spending. Most changes were relatively small, but in several countries public spending on health was lower in 2012 than it had been in 2007…

This crisis confirms what we knew from previous experience: economic shocks pose a threat to health and health system performance. They increase people’s need for health care, but make it more difficult for them to access the care they need. They heighten fiscal pressure, stretching government resources at the same time as people are relying more heavily on publicly financed health services. Negative effects on health tend to be concentrated among specific groups of people, especially those who experience unemployment, but can be mitigated by policy action…

Some health systems were better prepared than others to cope with severe fiscal pressure. Factors that helped to build resilience included countercyclical fiscal policies; adequate levels of public spending on health; no major gaps in health coverage; relatively low levels of out-of-pocket payments; a good understanding of areas in need of reform; information about the cost– effectiveness of different services and interventions; clear priorities; and political will to tackle inefficiencies and to mobilize revenue for the health sector. These factors made it easier for countries to respond effectively to the crisis. In contrast, weak governance and poor health system performance undermined resilience…. In responding to the crisis, most countries introduced positive changes. Many were resourceful in mobilizing public revenue for the health sector, sometimes in ways that brought additional benefits – introducing public health taxes, for example, or measures to make health financing fairer. The crisis prompted action to enhance financial protection, including extending health coverage to new groups of people and reducing or abolishing user charges. Faced with growing fiscal pressure, countries also took steps to get more out of available resources. Efforts to strengthen pharmaceutical policy were especially common. ‘’ Policy lessons identified in the publication include (among many):

‘’ Where spending cuts and coverage restrictions are the chosen course of action, they must be as selective as possible and informed by evidence of value. Within the health sector, arbitrary cuts to coverage, budgets, infrastructure, staff numbers and pay or service prices are likely to undermine efficiency, quality and access and unlikely to address underlying performance issues.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 As a result, they may cost the health system more in the longer term. In contrast, selective reductions informed by evidence and priority-setting processes can enhance efficiency… Not all spending achieves the same degree of benefit. It therefore makes economic sense to identify and limit spending on low-value (less cost-effective) areas and to protect spending on high-value (more cost-effective) areas, including public health services and primary care. Targeting excess capacity, inflated prices and low-value services, combined with a reallocation of resources to high-value services, will increase health gain as well as improving efficiency…. Secure financial protection and access to health services as a priority, especially for people at risk of poverty, unemployment, social exclusion and ill health. Economic shocks increase people’s need for health care and make it more difficult for them to access the care they need. They also affect some people more than others. Ensuring financial protection and access to health services is central to preventing deterioration in health outcomes and should therefore be a policy priority. A targeted approach may be needed to promote access for high-risk groups of people, particularly those who experience job loss. Effective health policy responses include addressing important gaps in coverage, strengthening protection from user charges and targeting richer households for cuts in tax subsidies or increases in contribution rates…. Focus on promoting efficiency and cost-effective investment in the health system. Strategies likely to generate both savings and efficiency gains in the context of an economic shock include strengthening pharmaceutical procurement, pricing and substitution policies to achieve the same outcomes at lower cost; reducing inflated service prices and salaries; restricting the coverage of health services already known to be of low value; stepping up the implementation of planned hospital restructuring; and merging health insurance funds to minimize duplication of tasks and redress fragmented pooling and purchasing… More complex changes that are unlikely to result in immediate savings and may require upfront investment – but will enhance efficiency in the longer term – include strengthening policies to promote health and prevent disease; greater use of HTA to inform coverage decisions and service delivery; restructuring to shift care out of hospitals and prioritize primary care; reform of provider payment methods, including efforts to link payment to evidence of performance; pursuing skill mix policies; and developing eHealth.’’

 Overall, do you think that the Europe 2020 strategy has made a difference? Please explain.

The analysis within COM (2014) 130 is reasonable, although limited and incomplete in terms of health and social impact. It forms the basis for EuroHealthNet’s specific critically constructive comments to follow.

Overall, many important potential stakeholders in health systems in all member states have not been significantly engaged despite serious efforts, including by EuroHealthNet and the European Commission, to address this gap. EU 2020, while of course democratically put in place by EU Institutional decisions, is widely perceived as inorganic, top down, imposed and potentially harmful to health and wellbeing objectives. Beyond parts of health ministries, in most states few in health systems and sectors have been consulted, properly informed except by stakeholders such as EuroHealthNet, or involved in planning. The role of health systems in tackling poverty, for example, could be significant; similarly on climate change and sustainability. There are major Europe wide collaborations on school wellbeing which can impact the smart targets. So overall

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 for the health sector, the first years of EU 2020 has not made a measurable positive difference, but that does not mean it cannot in the remaining period to 2020. Yet the negative impacts of many economic and fiscal measures are already substantial as the above WHO report sets out. That is not good governance for health or cost effective economic policy making in most cases.

EU 2020 is insufficiently integrated with health and social objectives of states to realise the potential positive added value of the EU. It insufficiently provides a relevant framework identifying impacts and gains for involving health and care systems, which are often the largest employers, most influential institutions in communities, regarded by citizens as most important to their individual and collective wellbeing. Too often they are simplistically seen as an economic burden or dispensable luxury to be cut.

EuroHealthNet strongly believes in reorientation of care and treatment systems as set out in the WHO Charters for Health Promotion and for whole health systems as defined in Europe by the WHO Tallinn Charter signed by EU member states. It believes these are compatible with the EU objectives mentioned above. We support change, integrated approaches, smart, inclusive and sustainable goals. But EU 2020 has (so far) made an insufficient tangible positive difference to that process in terms of ensuring development of smart, inclusive and sustainable whole of society and whole of government systems including health and wellbeing. It has not sufficiently addressed repeated calls in Council Conclusions for reorientation towards meaningful disease prevention and health promotion measures in cooperation with member states.

EuroHealthNet is therefore concerned that the ‘’detailed TEU objective (b) above for “an internal market where competition is free and undistorted’’ has and will be disproportionately prioritised above the other detailed objectives (a to f) above, to the detriment of the overarching objective to promote wellbeing and the provisions of Article 168.

EuroHealthNet reminds the EU Institutions of the agreement by EU member states in 2012 of the WHO Europe HEALTH 2020 strategy plus The Tallin Charter which was also recognized by former EU Commissioner Dali when the policy framework and strategy was adopted by all WHO/Euro Member States in Malta 2012.

http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for- health-and-well-being

http://www.euro.who.int/__data/assets/pdf_file/0008/88613/E91438.pdf?ua=1

EuroHealthNet stresses that health in certain aspects not only is a driver for health improvement, but also has a value in itself for people to lead good lives, as identified in the EU Health Strategy and Health for Growth Programme 2014 – 2020.

 Has the knowledge of what other EU countries are doing in Europe 2020 areas impacted on the approach followed in your country? Please give examples.

EuroHealthNet continues to work proactively and positively to raise awareness and engagement with public health actors in states of the relevant component parts of EU 2020 and the EU

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 Semester process. Within the provisions of the EU PROGRESS programme 2011-13 and the EaSI Programme 2014 – 17, EuroHealthNet is engaging partners and stakeholders in member states within the EU Poverty Programme, the EU Semester process including addressing relevant CSRs (which include a growing number of health system specific requirements), and towards effective use of a range of EU instruments including application of funds in states towards EU 2020 objectives. This has included initiating pilot partnerships within states (cross sectoral and cross- border); knowledge transfer; studies and training; consistent advocacy, communications, information and dissemination, and participation in initiatives organised by states, stakeholders and the EU institutions; all part funded by EuroHealthNet partners and with support from EU co- funded programmes where appropriate.

EuroHealthNet partly exists to support effective liaison between responsible authorities and bodies in member states and the EU institutions towards progress on the EU objectives mentioned earlier. That was the reason for its establishment two decades ago. It must be able to demonstrate EU added value to those partners, not least, for example, to those at sub national, regional and municipal levels who have implementing authority for achieving cross sectoral progress towards local smart, inclusive and sustainable goals which may not always match EU objectives. EuroHealthNet is doing much to engage such bodies, for example through involvement and learning from EU Joint Actions which primarily involve states, or from access to EU advisory bodies at state levels. The responsibility for managing and organising health and care systems clearly rests at state level within the TEU: however their delivery often relies on devolved or sub national authorities and stakeholders. Similarly, delivery on innovation objectives needs partners from centres of expertise or new forms of bodies from private or third sectors. EuroHealthNet continues to reform and modernise itself and to advocate for change, in line with these new paradigms, to be as supportive as possible in implementation of innovative approaches.

Therefore EuroHealthNet contributes to this consultation from a basis of proactively seeking to achieve common objectives and will be happy to provide examples of needs and approaches in particular states if requested.

 Has there been sufficient involvement of stakeholders in the Europe 2020 strategy? Are you involved in the Europe 2020 strategy? Would you like to be more involved? If yes, how?

No. There is a wealth of evidence about how the involvement of a wide range of stakeholders in design as well as implementation of strategic approaches is essential to success. This has not been the case in either the EU Lisbon or 2020 strategies, where stakeholder involvement has been largely ‘’bolted on’’ while inter-governmental mechanisms dominate. The reality is that ministries alone cannot deliver such objectives, and we comment as a partnership established and maintained with state support and involvement that wishes to contribute to successful states and a successful EU. The outcomes of the 2014 EP elections to a certain extent demonstrate Europe cannot afford to stop investing in engagement, inclusion, well-being and positive opportunities. This review is an opportunity to rectify that.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 There are of course complexities and differences that are inherent in greater involvement beyond state and EU institutions, but potential gains are significant. For one small example, it is perfectly achievable within current resources to initiate an annual Report and Debate in the EU Institutions on ‘’the state of public health in the EU’’ according to indicators which either exist or can be agreed at relatively short notice (the EU needs to do more to align with WHO Europe and OECD on applying common health and wellbeing indicators). That could contribute to the Semester process and to support the Article 168 provision (which is not being upheld satisfactorily) and help to identify common challenges and solutions, recognising diversities. EuroHealthNet is not responsible for all aspects of health but could initiate and contribute its part where its partners have responsibility.

Tools

 Do the current targets for 2020 respond to the strategy's objectives of fostering growth and jobs? Among current targets, do you consider that some are more important than others? Please explain.

[Targets: to have at least 75% of people aged 20-64 in employment; to invest 3% of GDP in research and development; to cut greenhouse gas emissions by at least 20%, increase the share of renewables to 20% and improve energy efficiency by 20%; to reduce school drop-out rates to below 10% and increase the share of young people with a third-level degree or diploma to at least 40%; to ensure at least 20 million fewer people are at risk of poverty or social exclusion].

EuroHealthNet seeks to help implement an approach of health for all policies and practices at all levels, including the EU. Therefore while we are most directly engaged in the Poverty Platform we are concerned with all EU2020 targets. Until that approach is fully integrated the provisions of the Treaty cannot be achieved.

Comm. 130 refers more than once to ‘’a growing divergence across and often within member states’’; that there is significant ‘’societal change’’ and ‘’inequality has risen in Europe’’. It concludes that ‘’convergence has slowed and/or reversed’’. While understanding the point made that ‘’there is a need to avoid dilution of priorities and to focus on essentials’’ which we support, we contend that measuring and addressing inequity and positively fostering convergence are essentials to meet EU objectives, which EU 2020 currently misses. The latest Social Justice Index shows the cost of austerity: a strategy for growth and jobs alone is not the correct priority.

We wish to stress that EuroHealthNet follows the WHO Charter definition of health as ‘’not only the absence of disease but a complete state of physical, mental and social wellbeing’’. It is clear how the EU objectives can align with health for all policies approaches, seen as a contribution to sustainable and equitable development rather than a burden or based on more narrow definitions of heath and care systems.

Therefore, while making points elsewhere about some specific sub targets (for example concerning ageing and for poverty), EuroHealthNet believes that

(a) Current EU competences offer reasonable bases for fully implementing EU objectives

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 (b) That it is more important to integrate a headline objective for equity which will have cross cutting effect.

Alternatives exist for such a goal – bearing in mind we will explain that we believe milestones to be a more appropriate than targets unless real EU wide performance accountability is ensured, unlikely given subsidiarity principles. We therefore call on the EC to instigate a consultation of informed stakeholders on an appropriate equity goal and indicators within the timescale we suggest later (2019 – 2024 – 2029).

 Do you find it useful that EU-level targets are broken down into national targets? If so, what is, in your view, the best way to set national targets? So far, have the national targets been set appropriately/too ambitiously/not ambitiously enough?

Comm 130 makes it clear that the EU 2020 targets are ‘’essentially political objectives’’. National political cycles are not aligned with EU strategic cycles and subsidiarity applies. Sub national (regional, municipal, metropolitan, local, community) cycles, goals and objectives may even more sharply differ. Health systems may be the legal responsibility of states, but their performance is often organised and increasingly determined and carried out at sub national levels which vary across the EU. Therefore targets do not currently mean accountability. It is welcome that the review of EU 2020, unlike the Lisbon mid-term review, has been extended for public consultation and to cover the period of the European parliamentary elections, allowing extended reflection and debate. However that can be improved further for democratic benefit.

An approach of ‘’measuring posts’’ (milestones) is needed to gauge progress meaningfully against goals at all levels. But we suggest that the crucial milestones are needed to correspond with the 5 year cycles of the EU institutions and therefore are appropriate for 2019, 2024 and 2029 to allow time for reflection before the end of elected or appointed terms in 2020, 2025 and 2030. That would give citizens a way to judge progress or failure, take into account when voting at Europe-wide elections, before renewing appointments, and before initiating further new strategic periods.

 What has been the added value of the seven action programmes for growth? Do you have concrete examples of the impact of such programmes? ["Flagship initiatives": "Digital agenda for Europe", "Innovation Union", "Youth on the move", "Resource efficient Europe", "An industrial policy for the globalisation era", "Agenda for new skills and jobs", "European platform against poverty"].

1. Digital Agenda for Europe:

The scale and pace of technological challenge was among the priority areas identified by the EU Health Policy Forum in its submission on the formation of the EU health strategy and programme. It is entirely appropriate for a multi- national EU to address those challenges, which supercede most national resources and capacities to legislate and develop. So the programme has great importance and added value.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 However, while recognising that there is awareness of risks and need for better assessment, EuroHealthNet has major concerns about premature adoption within public systems, including health, of technologies for which social, economic, environmental and health impacts are unproven and may require long term evaluation. EU initiatives on health technology assessment will be valuable. But the risk of increasing exclusion, plus insufficient attention so far to improving literacy for all, including health literacy, is of concern.

Equitable access to innovative technologies is vital, from design to regulation and application. New technologies need to be accessible for people across social gradients, particularly those who are disadvantaged and more vulnerable to ill-health, chronic and poverty related conditions, disabilities and lower life expectancies.

EuroHealthNet is part of EU co-funded studies which will propose key measures for health literacy, but also cautions against replacement of people in employment by technologies on the grounds of cutting costs as counterproductive to the strategic goals for 2020 for inclusion. We note that targets for access to online facilities envisage maximum 80% of populations, implying a fifth of people will still be excluded. EuroHealthNet is working with the EU and WHO to develop communication, media and social empowerment tools.

2. Innovation Union

EuroHealthNet is supportive of the Innovation Partnership on Healthy & Active Ageing but not necessarily of its headline target, preferring a quality of life indicator to be applied rather than life expectancy alone.

While supportive in principle of Horizon 2020 objectives and its alignment within EU 2020 strategic priorities, programme practice is worrying in terms of addressing societal challenges, which do not so far reflect the potential for added value in tackling inequities and determinants of health and wellbeing.

EuroHealthNet has created a new Centre for Implementation for Research and Innovation to step up efforts to ensure the innovation – evaluation – policy – practice cycle is better developed for health and wellbeing. The extended use of open source data is vital.

The role of the ECDC could be considered for strengthening in terms of provision of evidence for policy making in association with other relevant EU agencies, in alignment and support with Member State research bodies.

3. Youth on the Move

EuroHealthNet considers that current levels of youth unemployment represent a public health emergency, and threaten social justice and cohesion. It has been part of EU co-funded studies which indicate the health and social evidence for the urgency of increasing opportunities for younger people in employment, education and training, and has proactively engaged national members in sharing ideas and initiatives through its networking and study modules.

However this is an area where highly variable engagements have been made with health sectors, including helping member states to strengthen employment, training and apprenticeships in public

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 health professions, and also to help ensure better health education, including for mental wellbeing, for all. EuroHealthNet welcomes the aims to increase proportions of people reaching tertiary education standards and reducing early school leaving as important social determinants of health.

4. Resource Efficient Europe

EuroHealthNet has contributed to EU co-funded studies on sustainable development and considers that the EU potentially brings major added value to states which benefit public health and wellbeing, ranging from multiple environmental legislative acts to measures affecting production and consumption.

However there are concerns that the ‘’better regulation’’ approaches have weakened this value in favour of short term business objectives which rarely translate in real employment gains. Fuel poverty is a major factor affecting health equity; unhealthy product subsidies are contributing towards obesonegenic environments; helpful transport objectives concerning safety and pollution are not being achieved.

It is important that the standards and commitments of the EU Institutions meet the requirements of health protection in all EU policies and are t compatible with what is agreed by states in the WHO Europe context, for example within the context of the WHO Europe Working Group on the impacts of climate change and health: http://www.euro.who.int/__data/assets/pdf_file/0005/186242/e96844.pdf?ua=1

Overall the EU 2020 strategy misses a coherent sustainable development core, to which health systems can make major contributions directly and in partnerships.

5. Industrial policy

The WHO Commission on social determinants of health identified rapid globalisation as a negative factor for health and wellbeing and called for change. EuroHealthNet sees many private sectors, including manufacturing, energy and service sectors, as vital potential partners to work for sustainable development and wellbeing, but the approach within EU 2020 too often decouples the potential mutual benefits from social innovation and development in favour of limited definition growth objectives.

Assessment practices should look at multiple co-benefits rather than see health protection and equity as negative factors in industrial development. Greening economies, effective use of technologies, innovative ideas for social gains, and inclusive health improvement itself offer major 21st century prospects where EU industrial policy can be regenerated and lead. Health systems have much to contribute which is yet untapped; healthier people mean healthier markets.

6. Agenda for skills and jobs

Clearly linking with priorities for young people (above), the evidence that being in work benefits wellbeing is clear. Work towards increasing and maintaining employment is essential, but so is evidence that being in good quality employment with decent working conditions is better, with societal co-benefits including active, healthier ageing.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 EuroHealthNet has led EU co-funded studies on determinants of social capital and wellbeing through the life course. While it supports the EU 2020 aims, much more needs to be done to ensure fair employment practices including strengthening health and safety practices; for establishing healthy living wage goals to move beyond essential minimum income protection; to ensure effective and equitable social protection from maternity and childcare to employment protection and pensions across the whole EU. The EU added value is clear. Without such measures the Treaty objectives cannot be met,

7. EU Platform against poverty

Last but very much not least, the actions towards achieving poverty reduction targets, the aspect in which EuroHealthNet has been most directly involved as part of the Convention and stakeholder process, have been fragmented and unsatisfactory despite highly creditable efforts by EC officials and others.

EuroHealthNet notes the Joint Opinion of the Employment and Social Protection Committees (13809/14) regarding targets; interim milestones for member states towards the targets; the need to improve the effectiveness and role of the Convention; potential improvements in addressing gender equity and other social elements of the EU2020 and EU Semester processes. EuroHealthNet will continue to work with its partners in states to take up these recommendations and act as appropriate to support progress.

We would like to see more commitment by states, as this will foster opportunities for progress. The situation concerning child poverty, homelessness, in work poverty, intergenerational and migrant disadvantage and gender inequity shames us all. This should be the most urgent and important flagship, the great cohesive challenge for every community and actor, but the over-stimulation of competition before cooperation too often distorts progress, negates needs and reduces quality, including in EU programmes such as research.

The instruments available need to be more coherent and cohesive from the Semester to funding programmes, the targets or milestones sharper, the political and sectoral accountability more defined. The approach of the Social Investment Package should be taken forward in integrated programmes and policies. Stakeholders such as EuroHealthNet are willing to be more effectively engaged but this needs to be at the centre of the EU 2020 strategy for 2015 onwards.

2) Adapting the Europe 2020 strategy: the growth strategy for a post-crisis Europe

Content and implementation

 Does the EU need a comprehensive and overarching medium-term strategy for growth and jobs for the coming years?

Yes, but as set out above, with sharper 4-5 year milestones linked to the EU Treaty, its institutional cycle, and has to be much more inclusive. It also needs to be part of a real longer term sustainable development strategy.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 It is important to re-state that the assumption that the EU is ‘’post crisis’’ is flawed and does not match the evidence nor reality for many EU citizens, nor for global partners. Many health impacts of austerity approaches have been delayed or deferred. Examples include’:

- The health and social impacts of youth unemployment will impact through the life-course.

- The inequitable impacts on non-communicable diseases and mental wellbeing will be increasingly felt within states.

- Many workplace health programmes have fallen victim to cuts.

- Changes to employment practices with less security mean less engagement by employees.

- Child poverty is increasing; increases to in-work poverty and poverty across the life-course will have significant health impacts; early years care and child/adolescent support services are prone to reductions with significant short, medium and long term health and social impacts;

- Support to older people is diminishing; long term care provisions are being reorganised in such a way that some older people become even more vulnerable. Support services are prone to cuts with huge health and social impacts. EuroHealthNet notes and is acting on the 2014 recommendations of the Joint SPC and EC report on social protection for long term care needs in ageing societies.

- Proportions of expenditure allocated to health promotion have fallen widely: there is insufficient capacity in most states and communities to achieve objectives. This is unlikely to be rectified in budget planning periods before 2020 without priority changes which can be stimulated within the EU 2020 and Semester processes.

 What are the most important and relevant areas to be addressed in order to achieve smart, sustainable and inclusive growth?

1. Equity.

2. Wellbeing

3. Sustainable development.

All are as in the TEU objectives mentioned earlier. All are part of global processes and commitments in which the EU is involved and can lead.

Comm. 130 points out that the OECD and others are developing acceptable indicators beyond GDP. Economic and other evidence towards those needs for successful development is becoming overwhelming.

 What new challenges should be taken into account in the future?

Inequality. The evidence is increasingly overwhelming of how inequality harms societies and economies. We know enough to act. It is a matter of political choice. EuroHealthNet and its partners

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 have long been involved with national and sub national, EU, WHO global and European publications of evidence and recommendations on social determinants of health inequalities, including the reports cited here: http://www.euro.who.int/en/health-topics/health-determinants/social-determinants http://www.who.int/social_determinants/en/ http://www.equalitytrust.org.uk/resources/spirit-level-why-equality-better-everyone

 How could the strategy best be linked to other EU policies?

An improved overarching assessment framework should be implemented including equity impact, the mechanisms for which are now known and established. Without it serious lack of cohesion will increase the most serious risk of conflict.

We note the proposed new composition of the portfolios of the College of Commissioners and are concerned several choices made will impede the progress we seek. We reiterate the need for a properly integrated institutional approach to the priorities set out above.

We emphasise that insufficiently supported, albeit well-meaning and valid, efforts to ‘’share good practices’’ often founder without effective regulatory environments to tackle problems and negative factors which hinder actions – for example in developing equitable, healthier markets.

We refer in particular to the need to tackle obesogenic environments, strengthen and implement measures to prevent tobacco use and alcohol harm, to promote mental wellbeing and to address other diseases or conditions with social and economic implications.

Many are being increasingly considered globally in the context of the United Nations and goal setting in the context of the millennium Development Goals and the post 2015 agenda. We call on the EU and states to use all available knowledge and tools coherently to tackle threats to health, equity and wellbeing; and to ensure coherent alignment of strategies and policies both within the boundaries of the EU and globally, working in partnership with international organisations, states and stakeholders.

 What would improve stakeholder involvement in a post-crisis growth strategy for Europe? What could be done to increase awareness, support and better implementation of this strategy in your country?

Involvement in milestone setting and planning should be ensured, particularly for implementing agencies and sub national authorities such as regions and municipalities, and only then expecting accountable engagement towards their achievement, replacing the top down imposition by states and institutions prevalent at present.

Transparent access to information, for example via an accessible EU multilingual portal showing evaluation and effective use of EU funds in states and regions towards better knowledge transfer and good practice exchange.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647 Open source access to all publicly funded data and information, no commercial secrecy if public funding is involved; and such access as a condition before involvement in EC advisory processes and stakeholder bodies.

Tools

 What type of instruments do you think would be more appropriate to use to achieve smart, sustainable and inclusive growth?

We greatly value the work of EC officials to integrate health equity in programmes and policies while respecting competences. However, we urged in response to the 2009 Communication Solidarity in Health COM (2009) 567 that an institutional structure to underpin work on cross cutting inequalities would be necessary: that has proved correct; work within and between DGs and in states is now disconnected and insufficient, inequalities persist and grow which undermine EU 2020 objectives.

We are even more concerned after the publication of the proposed new College of Commissioners. In the context of the new EU programmes 2014-20 and towards achieving economic, innovation, education, sustainable development and poverty targets, we again call for senior level coordination of work in all EU institutions on building equity and tackling avoidable inequalities as is a duty within the Treaty objectives we identified in question 1 above.

 What would best be done at EU level to ensure that the strategy delivers results?

See answers above, plus accessible monitoring and evaluation, with a stronger role for European and national parliaments and stakeholders

 What would best be done at Member State level?

See earlier comments.

The European Parliament should play a stronger role in transparent monitoring and scrutiny.

Without sub national actors being better involved in design as well as implementation, the reality is much of EU 2020 will remain strategic on paper rather than impacting meaningfully.

 How can the strategy encourage Member States to put a stronger policy focus on growth?

See above comments on sustainable development.

 Are targets useful? Please explain.

See earlier comments on milestones and accountability.

 Would you recommend adding or removing certain targets, or the targets in general? Please explain.

As set out above, EuroHealthNet recommends including indicators for quality of life, wellbeing and equity, and to strengthen the poverty target.

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647  What are the most fruitful areas for joint EU-Member State action? What would be the added value?

We have suggested throughout our response that the three great untapped areas for EU added value for states and their citizens can be equity, wellbeing and sustainability. This can be an agenda for positive support and strategic impact, moving away from unsustainable, inequitable and harmful policies and practices with which the EU and state governments are increasingly associated.

3) Do you have any other comment or suggestion on the Europe 2020 strategy that you would like to share?

The focus is understandably on 2020, and we agree accountability should be built in for that milestone. But already there should be strategic consultation on longer term planning to 2030 and beyond using Foresight methodologies and other sources of evidence.

An EU that is involved more in long term strategic support and evaluation frameworks as a world region, and less in the detail of delivery, which is best defined and implemented locally as is very much the case for health promotion, would be a better EU.

Lastly, as we emphasis for every consultation response we contribute, EuroHealthNet reminds that this is a collective response of the partnership based on extensive internal consultations and discussions, including at its 2014 Annual General Meeting and meetings of its Executive Board. However, as always, individual members and partners as state agencies and organisations reserve the right to hold and express different opinions or perspectives and may not concur with all points made above. EuroHealthNet wholly supports diversity and encourages transparent knowledge sharing and discussion as an essential element of good governance and decision making.

About us: EuroHealthNet is a Partnership consisting of primarily responsible public health authorities and institutes working at regional, national and international levels across Europe. Our mission is to help improve population health and reduce health inequalities. The EuroHealthNet Office is based in Brussels, Rue de la Loi 67. Please see www.eurohealthnet.eu

Thank you for completing the questionnaire. Please send your contribution, along with any other documents, to [email protected].

Disclaimer: The views expressed in this response do not necessarily reflect the views of all EuroHealthNet’s Members and Partners

EuroHealthNet is co-funded by the European Union Programme for Employment and Social Innovation EaSI 2014-2020

EuroHealthNet ▪▪ Rue de la Loi, 67 ▪▪ 1040 Brussels ▪▪ Belgium ▪▪ T. +32 2 235 0320 www.eurohealthnet.eu N° Entreprise: BE 479.553.647